Orthostatic Hypotension in Patients With Left Ventricular Assist Devices: Acquired Autonomic Dysfunction

Abstract

Contemporary left ventricular assist device (LVAD) technology uses nonphysiologic continuous flow to deliver blood into the circulation. This results in a reduction of pulsatility, which is implicated in some of the commonly associated side effects with LVAD therapy, including hypertension and gastrointestinal arterial-venous malformation with related bleeding. A less frequently observed side effect is orthostatic hypotension (OH) in patients supported with LVAD therapy. We present three cases of OH in patients with LVAD, followed by a discussion on how LVAD therapy may induce autonomic dysfunction.

Heart Failure Association of the European Society of Cardiology position paper on the management of left ventricular assist device‐supported patients for the non‐left ventricular assist device specialist healthcare provider: Part 2: at the emergency department

“…This includes an abnormal sympathetic tone with a marked decrease in vasoconstrictive function, an offloading of carotid and aortic baroreceptors causing a loss of compensatory mechanisms with positional changes. 94 Further contributors to orthostatic hypotension include low intravascular volume state, medications with vasodilator properties, poor right ventricular function, and comorbidities like diabetes mellitus leading to secondary autonomic failure. Device-specific factors like malposition of the inflow cannula receive special attention.…”

“…This includes an abnormal sympathetic tone with a marked decrease in vasoconstrictive function, an offloading of carotid and aortic baroreceptors causing a loss of compensatory mechanisms with positional changes. 94 …”

“…Left ventricular assist device patients show an increased susceptibility for orthostatic hypotension, resulting from pathophysiological properties in CF and in HF in general. This includes an abnormal sympathetic tone with a marked decrease in vasoconstrictive function, an offloading of carotid and aortic baroreceptors causing a loss of compensatory mechanisms with positional changes 94 …”

Surface mapping demonstrates compatibility of implantable loop monitor with a continuous‐flow left ventricular assist device

“…Orthostatic hypotension or dysautonomia may account for 12-30% of severe dizziness/syncope in such patients. 1,2 While bradyarrhythmia or tachyarrhythmia are generally tolerated, associated haemodynamic instability has been noted to occur in some studies in up to 10-13% of patients with LVAD. 3,4 Current management guidelines for patients with LVAD without pre-existing implantable cardioverter defibrillator recommend observation without device therapy if there is no history of pre-operative ventricular arrhythmia.…”

“…The aetiology of syncope in patients with continuous‐flow left ventricular assist device (CF‐LVAD) may be difficult to determine in the absence of a pacemaker or defibrillator. Orthostatic hypotension or dysautonomia may account for 12–30% of severe dizziness/syncope in such patients 1,2 . While bradyarrhythmia or tachyarrhythmia are generally tolerated, associated haemodynamic instability has been noted to occur in some studies in up to 10–13% of patients with LVAD 3,4 .…”